critical“Risks to people's health, safety and welfare had not been consistently assessed. There was a lack of guidance for staff about how to keep people safe.”
staff competency
1 finding
moderate“There was no detailed guidance to ensure staff used the hoist safely. There was a risk new staff may not have the step by step guidance to ensure people were moved safely.”
staff training
1 finding
moderate“When a person had a catheter...there was no information to guide staff to the possible risks of infection, for example changes in the colour of urine.”
governance
1 finding
critical“Systems to assess, monitor and improve the quality and safety of the service had not been operated effectively. This is a breach of Regulation 17.”
record keeping
1 finding
moderate“Some checks and audits had not been recorded regularly...office staff made sure that late calls were monitored...however, this was not recorded.”
leadership
1 finding
critical“There was no registered manager at the service...The nominated individual did not have clear oversight of the day to day running of the service.”
incident learning
1 finding
critical“We identified 2 incidents...reported to the local safeguarding authority, that had not been reported to the Care Quality Commission (CQC) in line with guidance.”
supervision appraisal
1 finding
minor“One to one staff supervision meetings had not been held regularly. This had been identified and staff had begun to meet with their line managers.”
safeguarding
1 finding
critical“Checks had not been consistently completed to make sure new staff were safe to work with people...a staff member's file noted they had provided 2 references. There was no reference on file.”